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Quality of life tool for inspecting services for people with a learning disability

Categories:
  • Organisations we regulate

This tool sets out areas to explore when we inspect services for people with learning disabilities.

The quality of life tool was developed in order to address recommendations from Glynis Murphy's first report into the regulation of Whorlton Hall; and recommendations in CQC’s restrictive practices review (Out of sight – who cares?). 

The primary purpose of the quality of life tool is to improve CQC's ability to consistently identify and take appropriate regulatory action in services that fail or are failing to meet the needs, aspirations and skills development of people with a learning disability and/or autistic people. The tool looks at how well people's care plans are delivered in practice. 

The early development of the tool was completed with colleagues from Warwick and Bangor Universities. We look forward to being able to evaluate it and our wider approach when the piloting phase is complete. 

When the pilot process has concluded, we will be considering the results of the evaluation and we will determine how to continue to use the quality of life tool and other aspects of our methodology in the future. 

We have published two things: a version of the tool that is being piloted in some CQC inspections, and a broader framework that the tool was based on, but which has not been piloted.

How we use the quality of life tool when we carry out an inspection

The tool includes indicators that help inspectors identify areas to explore as they assess quality and safety. The indicators help them consider:

  • quality issues ('red flags')
  • regulations and articles of the Human Rights Act.

After the inspection has taken place, we use the tool to review the evidence and reach our judgement. We also use it to put together our report.

It helps us collect and compare evidence from different sources

The tool helps us corroborate evidence between different sources. These include:

  • documentation
  • what we see in the culture of the service
  • the physical environment
  • what staff, people who use the service, families and other stakeholders tell us.

For example, we might look at different sources to understand if the service is delivering what's in people's care plans. This could include:

  • looking at social media or diaries
  • asking for photos
  • speaking to people who run other settings like education services or day activities.

The tool focuses on the experience of the person receiving care and how it feels for them using the service.

The quality of life tool has not replaced our published methodology for assessing and evaluating the performance of registered providers; the KLOEs remain in place under the five key questions as the focus of our inspections against the fundamental standards set out in the Health and Social Care Act regulations. The quality of life is being piloted for inspectors to assist them in highlighting good and poor care in line with our KLOEs.

Human rights content is reflected in both the key questions and fundamental standards although we do not inspect a provider's compliance with the Human Rights Act itself. CQC will take the necessary action using our enforcement powers against breaches of our fundamental standards.


Section 1: Is there a planned programme for each person that focuses on their quality of life?

1. Is the physical environment appealing and does it meet people's sensory and physical needs - and is the culture kind, caring and nurturing?

Positive indicators

  • Appealing physical environment for all, reflecting sensory needs
  • Reasonable adjustments made where applicable
  • Empathetic and dignified social and interactive environment
  • Staff, the person and carers speak positively about the physical environment and culture or are able to indicate it meets their needs, including sensory.

Red flags

  • Poorly maintained or dirty fixtures and fittings
  • Bright lights
  • Noisy
  • No attempt to meet individual sensory needs
  • Inflexible or limited access to outside space
  • Blanket measures
  • Limited access to or use of communication support tools or plans.

Regulations

Human Rights Act

Key questions

  • Effective
  • Caring
  • Responsive

2. Do staff know the people they are supporting, including their health and wellbeing needs?

Positive indicators

  • The staff team support people consistently and understand their communication needs
  • People enjoying activities that they like to do including in the evening, opportunities to try different activities
  • Activities are tailored for individuals
  • Staff actively promote equality and diversity in their support to people, are respectful of diversity and protected characteristics, including how activities are offered
  • People have an active role in maintaining their own health and wellbeing, including annual health checks, access to screening and primary care services
  • People have a communication plan in place which meets their needs, which staff are aware of, understand and use.

Red flags

  • No access to external health professionals or visiting from them
  • People have limited access to or engagement with their community
  • Wellbeing plans provided by health professionals are not followed

Regulations

Human Rights Act

Key questions

  • Safe
  • Effective
  • Responsive

3. Are people engaged in meaningful activities and relationships?

Positive indicators

  • People choose and communicate when they'll next see family or carers
  • Staff, people and their carers talk about activities done and future plans
  • Staff support people to actively engage and try new activities, not just participate
  • Records and support plans evidence family and carer contact and activity choice.

Red flags

  • No records of outside activities or evidence of day to day choice
  • No records of carers visits, phone calls or video calls
  • Staff unenthusiastic and fail to encourage people's independence
  • Staff dismiss requests for activity or food choices out of hand, including those relevant to protective characteristics - for example, due to cultural or religious preferences.

Regulations

Human Rights Act

Key questions

  • Caring
  • Responsive

4. Are staff supporting people to experience real choice and control?

Positive indicators

  • Staff offer choices tailored to the individual using open questions
  • People exercise control over activities and staff enable flexibility
  • People have choice over personalising room and carer visit times
  • Behaviour support plans record preferences including communication
  • Support plans are accessible to people including language used, symbols, photographs, etc
  • There is an at-a-glance or one-page profile with the essential information and dos and don'ts. This is to ensure new or temporary staff can reduce the likelihood of someone having a bad day by following how best to support them.

Red flags

  • No record of choice in how people's day unfolds
  • Staff do not encourage engagement in tasks or activities
  • Overprotective care even if well-intentioned
  • Avoidance of involving people in activities due to perceived risk.

Regulations

Human Rights Act

Key questions

  • Safe
  • Effective
  • Caring

5. Are staff promoting a safe, consistent and predictable atmosphere that meets people's individual needs?

Positive indicators

  • Individualised support - for example, tailored visual schedules are used to support understanding
  • Staff support people's independence in planning their day or week
  • Staff support unplanned changes and assess risks continuously
  • Plans show evidence of positive risk-taking approach.

Red flags

  • No evidence of risk assessments for building or environment
  • No evidence of risk assessment for activity participation
  • No evidence of positive risk taking
  • No structure to a person's day and person left uncertain.

Regulations

Human Rights Act

Key questions

  • Safe
  • Effective
  • Responsive
  • Well-led

6. Are complex needs and behaviours that challenge being supported effectively?

Positive indicators

  • Staff are skilled and proactive in reducing challenging behaviour using plans personalised for each person rather than a single approach
  • Staff are alert to emotional communication and address signs of distress, frustration, etc
  • Staff support the person after an occurrence of behaviour that challenges, following the protocol detailed in each person's behaviour support plan
  • Functional assessments are co-produced with person and carers
  • Behaviour support plans are clear, detailed and used by all staff.

Red flags

  • Staff use same strategy for every person
  • Failure to recognise less obvious risky behaviours - for example, freezing
  • Behaviour support plans do not include teaching skills targets
  • Staff offset responsibility or ownership of challenge to others
  • Use of positive behaviour support plans from previous settings with no or little attempt to modify or update
  • Staff use inappropriate language such as “kicking off”.

Regulations

Human Rights Act

  • Dependent on outcomes - consider if failure to support people's distress leads to excessive restraint (see question 7 red flags)

Key questions

  • Safe
  • Effective
  • Responsive

7. Is there a clear commitment to minimising the use of restrictive interventions (including restraint, seclusion and segregation) and are they only used as a last resort?

Positive indicators

  • Unplanned use of restrictive strategies triggers review of support plan
  • Evidence that staff and the people who were subject to restrictive interventions are de-briefed and carers informed
  • Staff discuss techniques that promote reducing restrictive practice
  • Staff can give examples of post-debrief updates to support plans.

Red flags

  • Poor or absent record of monitoring use of restrictive interventions
  • No evidence of clear reducing restrictive intervention plan in place
  • Staff say no alternative and adopt restrictive interventions first
  • No evidence of reflective practice or debriefs post incident.

Regulations

Human Rights Act

Key questions

  • Safe
  • Effective
  • Well-led

8. Is there effective practice leadership and support for service staff wellbeing?

Positive indicators

  • Arrangements for staffing including skills and numbers to reflect people's needs
  • Managers work directly with people and take a coaching approach with other staff
  • Managers set a culture that values reflection and learning
  • Staff say they can raise concerns with managers and feel safe.

Red flags

  • Staff say or indicate that they do not feel safe at work
  • Staff say or indicate that they cannot raise concerns
  • There is a high turnover or use of agency staff
  • Supervision, appraisal or staff meeting records with the same content for all staff.

Regulations

Human Rights Act

  • Dependent on outcomes

Key questions

  • Safe
  • Effective
  • Well-led

9. Is there an effective programme of service staff training and is there evidence of this being embedded into practice?

Positive indicators

  • Evidence of ongoing supervision and recognition of good practice
  • Evidence of understanding and compliance with legal requirements including human rights
  • Quality training to meet people's needs - for example, autism, learning disability, trauma-informed care, all of which includes relevant human rights issues
  • Workforce development plan in place.

Red flags

  • No or poor records of staff training or CPD
  • Staff not able to talk about training and how it relates to the people they support
  • No clear procedures for supporting team working or peer support
  • Poor or no supervision records.

Regulations

Human Rights Act

  • Dependent on outcomes

Key questions

  • Safe
  • Effective
  • Well-led

Section 2: Are the planned programmes relevant to each person's needs?

10. Has each person's programme (or programmes) been developed to meet their current needs and preferences as well as longer-term aspirations?

Positive indicators

  • Up-to-date assessments including medical, psychological, functional, preferences and skills
  • Programmes include details and methods of communication needs
  • Contributed to by person and family - and feedback that it is actioned
  • Includes autonomy-enhancing strategies, and supported by staff
  • Sets out current needs and pathway to future goals, including skills teaching
  • Staff discuss ways of ensuring targets are meaningful to person.

Red flags

  • There is no evidence of future planning or consideration for the longer-term aspirations of each person.

Regulations

Human Rights Act

  • Dependent on outcomes

Key questions

  • Safe
  • Effective
  • Responsive
  • Well-led

11. Do staff monitor and evaluate each person's outcomes meaningfully and review their support plan, adapting it where necessary?

Positive indicators

  • Relevant information and progress collected and used to update support plans
  • Continuously recording outcomes - for example, skills, behaviour challenges
  • Staff provide feedback on support provided, which updates plans
  • Staff talk positively about progress and ensure support evolves.

Red flags

  • No data is collected about how people are progressing or struggling with activities and tasks, or data is rarely collected and does not inform current behaviour protocols or support plans
  • There is no evidence of support plans having been updated - or if they have, they include the same protocols or targets as previous versions.

Regulations

Human Rights Act

  • Dependent on outcomes

Key questions

  • Effective
  • Responsive
  • Well-led

12. Are relevant stakeholders (including the person and their family) involved in the development of the person's support plan in a meaningful way?

Positive indicators

  • Families or carers involved in developing support plan and updates
  • Multidisciplinary team members sighted and involved in care plans where appropriate
  • Families and carers involved - for example, in provider policy review and development, and recruitment
  • There is information about independent advocacy and support
  • Staff empower people's decision making and evidence use of the Mental Capacity Act
  • Stakeholders describe how they've contributed and records back this up
  • Stakeholders speak positively about opportunities to feedback.

Red flags

  • No involvement of multiple stakeholders in the development of people's support plans or behaviour support plans
  • No involvement of family members, guardians or carers in the continuous development of the service (for example, staffing and recruitment)
  • Supporting the emotional wellbeing of stakeholders (and in particular family and carers) is not within the remit of the service, or is not considered by the service.

Regulations

Human Rights Act

  • Article 5: Right to liberty or security (does use of restrictive practices reach the threshold for a deprivation of liberty that is avoidable or may not be authorised through, for example, the Mental Capacity Act Deprivation of Liberty Safeguards?)

Key questions

  • Effective
  • Responsive

Section 3: Is each person's support programme being delivered at the right level of intensity?

13. Does each person's programme offer sufficiently intensive learning opportunities to help them acquire skills?

Positive indicators

  • People learn new skills appropriate to their needs and that promote stretch
  • Plans evidence targets that build on people's existing skills
  • New skills taught regularly, consistently and at right frequency
  • Evidence of exact process of skill teaching - for example activity scripts used
  • Skills taught in line with person's individual preferences
  • People engaged consistently throughout the day in all activities
  • Staff speak knowledgeably about tailoring level of support
  • Person and family or carers talk about skills they've learnt and skills they want to learn.

Red flags

  • Skills teaching rarely occurs
  • No evidence of continuous learning or skills teaching conducted by staff
  • Rather than teaching a skill, staff are doing the task for the person
  • Staff are inconsistent in how they teach specific skills to a person, increasing the likelihood of failure to learn the skill. This potentially results in frustration and behaviour that challenges.

Regulations

Human Rights Act

  • Dependent on outcomes

Key questions

  • Caring
  • Responsive

14. Do staff know the protocols for each person and their own role in the delivery of the support plan?

Positive indicators

  • Staff confident in applying support plan - for example, behaviour and teaching
  • Staff deliver support consistently
  • Staff can explain their role without needing to refer to documents
  • Staff explanation of their role matches with observation and support plan
  • Staff speak confidently to protocols for behaviour that challenges
  • Staff explanation of protocols matches the person's behaviour support plan
  • Staff support roles are detailed in each person's support plan.

Red flags

  • Staff do not know their roles within each person's support plan or the person-specific protocols for addressing behaviours that challenge
  • Staff are not consistent in the way they support people to manage behaviours, approach teaching targets or teach people skills.

Regulations

Human Rights Act

  • Dependent on outcomes

Key questions

  • Safe
  • Effective
  • Responsive
  • Well-led

Section 4: Is there a balance of the programmes and support plans for each individual with coherence across settings and over time?

15. Is there a balance across multiple programmes, if relevant?

Positive indicators

  • Activities and support apportioned according to plan areas
  • Activity planning maps to aspirations and promotes quality of life
  • Staff speak about how multiple programmes work together
  • Support plans work together across areas - for example, behaviour plan and speech and language therapy plan
  • Programmes include advice or methods to promote sense of belonging
  • Programmes and plans line up with information from clinicians.

Red flags

  • Daily activities for each person do not match up with the programmes for that person
  • A disproportionate amount of time is focused on just one or two aspects of the support (for example, spending more time on occupational therapy exercises than skills building).

Regulations

Human Rights Act

  • Dependent on outcomes

Key questions

  • Effective
  • Responsive
  • Well-led

16. Is the support provided to the person seamless across services and between professionals involved in the person's life?

Positive indicators

  • Staff and others work within positive behaviour support framework
  • Staff and others offer choice, show kindness, respect and nurture people
  • Staff and others consistently offer same high-quality level support
  • Staff and others speak knowledgeably about each person
  • Staff speak knowledgeably about support provided by others
  • People and families talk positively about support across all aspects
  • Multi-disciplinary assessments work together - for example, medical needs in PBS.

Red flags

  • Difference in the quality of support provided by the service, staff and professionals
  • Support is organised around the service's needs, rather than the person's - for example, arranging rotas in a way most convenient for staff or activities offered based on staff availability.

Regulations

Human Rights Act

Key questions

  • Effective
  • Caring
  • Well-led

17. Does each person's plan reflect planning for the future and a progression towards longer-term aspirations, as well as providing continuity over their life journey?

Positive indicators

  • Service updates programme with stakeholder input as person evolves
  • Support given over time adjusts as natural changes occur for people
  • Activities and learning in daily routines build skills for longer-term goals
  • Staff speak about life development with insight into life goals
  • People and family talk optimistically about the future including goals
  • Programme sets out desired end goals agreed with stakeholders and people.

Red flags

  • No evidence or consideration for the desired aspirations or end-goals for each person
  • Little or no continuity across the lifespan for each person reflected in their support plan.

Regulations

Human Rights Act

  • Dependent on outcomes

Key questions

  • Effective
  • Responsive
Last updated:
12 October 2021